Original Article

Effect of Vaginal Hygiene Module to Attitudes and Behavior of

Pathological Vaginal Discharge Prevention Among Female
Adolescents in Slemanregency, Yogyakarta, Indonesia
Sumarah Sumarah; MPH, Hesty Widyasih

Department of Midwifery, Poltekkes Kemenkes Yogyakarta, Daerah Istimewa Yogyakarta, Indonesia

Received April 2017; Revised and accepted June 2017

Abstract
Objective: To determine the effect of vaginal hygiene module to attitudes and behavior of pathological
vaginal discharge prevention in adolescent girls in Sleman Regency, Yogyakarta, Indonesia.
Materials and methods: This present study is a quasi experiment with pretest and post-test control
group design. A total of 80 female students was selected randomly from two secondary schools at the
study site and then distributed equally to control and experimental group. Only participants in the
experimental group were given self-learning vaginal hygiene module to maintain vaginal cleanliness. A
questionnaire was used as an instrument to measure the attitudes and behavior of vaginal discharge
prevention. Paired and independent sample t-tests with significance level (p value) at 0.05 and
Confidence Interval (CI) of 95%were employed to compare the mean difference.
Results: There is a significant difference in the students’ attitude and practice of pathological vaginal
discharge prevention between intervention and control group. The students who have been exposed to
vaginal hygiene module for six months showed better attitudes and practice in pathological vaginal
discharge prevention compared to their counterpart in control group who do not receive any module.
Conclusion: The present study implied that vaginal hygiene module can be provided widely for female
adolescents at their early puberty. District health officers may work closely with schools’ health promoter
to reach the students and create a supportive environment for reproductive health discussion and forum
in order to achieve better adolescents’ reproductive health status.

Keywords: Vaginal Hygiene Module; Pathological Vaginal Discharge; Prevention; Adolescence; Attitudes;
Behavior

Introduction1 since this group of population is vulnerable to sexual

As a result of the past fertility decline, Indonesia is
now constituted of large portion of young people
aged 10-24 years old (1, 2). The increasing number of
young people also followed by an increasing concern
Correspondence:
Sumarah Sumarah, Poltekkes Kemenkes Yogyakarta, Jalan
Tatabumi No.3 Banyuraden, Gamping, Banyuraden, Sleman,
Kabupaten Sleman, Daerah Istimewa Yogyakarta, 55293, Indonesia.
Email: sumarahakbid@gmail.com
and reproductive health problems. Studies found,
adolescent females represent a newly menarche
group, and have their ownsusceptibility with the
influence of reproductive hormones (3). Vulvo-
vaginitis is the most common gynecological diseases
in prepubertal and adolescent girls (4), suffered by
more than 60 percent adolescents worldwide. Vaginal
discharge, erythenla, and pruritus were common as
the symptoms with Candida sp., Streptococci sp. and

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 Vaginal Hygiene Module for Adolescents
Enterococci sp. as the most frequent pathogen
involved (5, 6).
Vaginitis is commonly found among women at all
age, but the prevalence is higher among women at
reproductive age (7). Adolescents are prone to
vaginitis because there is a lack of labial fat pads and
pubic hair, small labia minora, thin vulvar skin and
the closeness of the vulva to the anal region. Young
adolescents are also low in glycogen, with neutral pH
and non-production of cervical mucus and poor local
immune system (4, 6). The likelihoods of infection
are also elevated by poor hygiene derived from lack
of knowledge in reproductive health, especially in
genital organs (4, 6). Low absorbed of underwear,
panty liner, and pads may increase the yeast
infection, especially when it’s used in a long period.
In some settings, the practice of inappropriate genital
washing such as using inappropriate intimate
detergents (6) and vaginal douching have been
pointed as the causes of infertility among women and
therefore is no longer recommended as methods in
genital organ washing (8, 9).
Moreover, high humidity as the general climate in
Indonesia may increase the probability of yeasts
infection such as Candida sp. It is estimated, yeast
infection contributed to 20-30 percent of the cases in
vaginitis. C.albicans and C.glabrata maybe found in
women with recent courses of antibiotics,
corticosteroid treatments or those who suffered from
diabetes. Pregnancy, exogenous estrogens, use of
broad spectrum antimicrobials, immunosuppression,
and possibly sexual intercourse are also found as the
predisposing factors of yeast infection. The recovery
of yeasts in girls during pubertal maturation is also
more frequent, generally associated with the presence
of vaginal Lactobacilli (6, 10).
As well as in other regions of Indonesia, the
number of female adolescents aged 10-14 in
Yogyakarta is estimated to increase every year, from
126,000 in 2014 to 132,000 in 2020 (11). Sleman as
the most populated district also risked to higher
burden of health problem with the increasing number
of adolescents, especially when discussion about
reproductive health and sexuality remains taboo in
Javanese context. Studies found, lack of reproductive
health knowledge has indeed brought young people
into a greater risk of unwanted pregnancy and
sexually transmitted disease, including HIV and
AIDS in their later life (12, 13).
Many female adolescents are having poor
reproductive health practice. Although they
 Journal of Family and Reproductive Health http://jfrh.tums.ac.ir
acknowledge vaginal discharge as the vaginitis
symptoms, many do not understand the cause and
prevention. Preliminary study in Sleman State
Secondary School revealed that 80 percent of
students experiencing vaginal discharge. Of them, 60
percent reporting continued whitish or yellowish
discharge of mucus from the vagina during the past
three months. This study aims to determine the effect
of vaginal hygiene module to attitudes and behavior
of pathological vaginal discharge prevention in
adolescent girls in Sleman district, Yogyakarta,
Indonesia.
Materials and methods
The present study is a quasi experiment with pretest
and post-test control group design. It examined the
effect of the provision vaginal hygiene module to the
attitudes and behavior of pathological vaginal
discharge prevention in adolescents. Following the
large number of cases of vaginal discharge among
teenagers in Sleman regency Yogyakarta, a total of
80 female students was selected randomly from two
secondary schools in the study site. The involved
adolescents were then distributed equally to control
and experimental group. Only participants in the
experimental group were given self-learning vaginal
hygiene module to maintain vaginal hygiene.
A questionnaire was employed as an instrument to
measure the attitudes and behavior of vaginal
discharge prevention in female teenagers representing
by the total score of cognitive, affective, and conative
assessment. The pretest was given before the
participants obtained the module. The posttest was
done 6 months after the first observation. Paired t-test
was employed to decide whether the mean score of
the observed variables from pre and posttest is
significantly different while independent sample t-test
was used to find the significant mean difference
between control and experimental groups. Statistical
analysis was performed with significance level
(p value) at 0.05 and Confidence Interval (CI) of 95%.
The present study obtained its approval from
Ethical Committee Board of Politeknik Kesehatan
Kemenkes Yogyakarta (Yogyakarta Health
Polytechnic), Indonesia, with reference number
LB.01.01/KE/XVII/097/2016, on April 26th, 2016.
Results
Generally, most of students from both intervention
and control group lived in urban settings although the
proportion of respondents in intervention group who
Vol. 11, No. 2, June 2017 105
 Sumarah and Widyasih

lived in rural area slightly lower than the proportion
of respondents in control group. Initially, the vaginal
hygiene practices of students in intervention group
were observed slightly better in washing hands
practice, choosing menstrual pad, wearing cotton
fabric panties and the selection of daily outfits. At the
other hand, students in control group were better in
terms of changing panties and changing menstrual
pads. After the provision of vaginal hygiene module,
more students in intervention group showed better
vaginal hygiene practices compared to their control
counterpart. As it shown in table 1, the vast majority
of respondents in both intervention and control group
depicted a good practice in changing menstrual pads,
but not in wearing cotton fabric panties and changing
panties after exercise. The percentage of students who
change panty liners at least 4 times a day significantly
increased from 2.5% to 37.5% whilst those who used to
wear tight jeans are now wearing loose pants. Students
in the control group on the other hands, did not show an
improvement in their practices.
The students in the intervention group showed an
improved attitudes after the provision of vaginal
hygiene module. Initially, only 5% had correct
attitudes of vaginal douche products but after the
intervention, 45% had positive attitudes as expected.
The students also showed better attitudes toward
changing panties after exercise, showed by the
percentage who agreed was increased from 15% in
the beginning to 32.5% after the introduction to
vaginal hygiene module. The students who were less
likely to change their pads at school, changed their
thoughts and believed after the correct information
was provided. Although significant attitude changes
were observed in terms of changing menstrual pads
while at school, it should be noted that the students’
knowledge on the use of soap as vaginal douche was
lacking. After intervention, it was only 15% of
students in the intervention group and 7.5% of
students in the control group understood and had a
correct attitude.
Table 2 presents the mean score (± standard
deviation) of attitudes and behavior to vaginal
discharge prevention among the participants at the
first and second observation. The findings indicate
the mean difference of students’ attitude and behavior
score at the beginning in both control and
experimental group is not significant. The data
suggests that at the second observation the scores of
students’ attitude and behavior tend to increase.
Observed at the control group, the attitude score at
the control group slightly increased from
67.18 ± 4.517 to 69.00 ± 4.857, whilst the score of
behavior was monitored improved only at 1.15 point.
The significant changes of student attitudes and
behavior were noticed at the experimental group. The
attitude score obviously rose from 66.85 ± 4.023 to
76.12 ± 6.646 (p value < 0.001) whilst the behavior
score before and after given vaginal hygiene module
was remarkably different with an estimated value of
7.82 ± 4.187 (p value < 0.001).
From table 3, the mean differences of adolescences’
attitudes and behavior to the observed genital
discomfort between control and experimental group
were notably different (p value < 0.001). The data
suggests that the given vaginal hygiene module
significantly changes the students’ response to
pathological vaginal discharge prevention. The
students’ attitudes and behavior were scored better at
the experimental group than the control group.

Table 1: Percentage of correct practice in vaginal hygiene

Intervention Control
Vaginal hygiene practice (selected questions) (%)
Pretest Posttest Pretest Posttest
Changing panty liners at least 4 times a day 2.5 37.5 0.0 5.0
Washing hands before washing vagina 55.0 77.5 40.0 57.5
Changing panties at least 2 times a day 60.0 75.0 70.0 62.5
Sprinkle powder to vagina when it feels itchy 72.5 85.0 80.0 80.0
Changing panties after exercise 27.5 42.5 45.0 35.0
Choosing menstrual pads 42.5 72.5 35.0 37.5
Wearing loose pants for daily outfits 12.5 62.5 7.5 17.5
Wearing cotton fabric panties 27.5 55.0 7.5 15.0
Changing menstrual pads 80.0 90.0 87.5 77.5

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 Vaginal Hygiene Module for Adolescents

Table 2: The mean score (± standard deviation) of students’ attitudes and behavior of pathological
vaginal discharge prevention pretest and posttest in control and experimental groups
Score (mean ± std. deviation)
Variables Group 95% CI p value
Pretest Posttest
Attitude Control 67.18 ± 4.517 69.00 ± 4.857 -1.825 0,039
Experimental 66.85 ± 4.023 76.12 ± 6.646 -9.275 0,00
Behavior Control 50.65 ± 3.317 51.80 ± 3.611 -1.150 0,144
Experimental 51.15 ± 4.759 58.98 ± 4.252 -7.825 0,00

The score of students’ attitudes and behavior at
the experimental group was significantly higher after
the students exposed by the module, with a score of
9.28 ± 5.533 and 7.82 ± 4.187, respectively.
Table 3: The mean difference (± standard deviation) of
students’ attitudes and behavior of pathological vaginal
discharge prevention in control and experimental group
Variabel Group Score p value
Attitude Control 1.82 ± 5.406 0.00
Experimental 9.28 ± 5.533
Behavior Control 1.15 ± 4.876 0.00
Experimental 7.82 ± 4.187
Discussion
Social construction of Javanese culture has prevented
the discussion about reproductive health matters to
unmarried youth. About one fourth of young women
never talk with anyone about menstruation before
they have their first menses, and half of young men
never discussed wet dreams before their first wet
dream (1, 14, 15). Parents are the last person young
people seek for information regarding reproductive
health whilst schools only provide limited
information on anatomy and physiology of human
bodies. In the absence of adequate information,
young people mostly access media to fulfil their
curiosity regarding their own sexuality.
Unfortunately, given the nature of media as double-
edged sword in providing information, coupled with
limited searching skills, many youngsters are then
finally ended up to access unreliable sources of
information (16).
Studies found that school is proven as a reliable
source of reproductive health information for young
people. Adolescents who obtain adequate and
accurate information from schools are more likely to
have better knowledge, attitude and reproductive
health behavior (12, 13). Nevertheless, because
providing reproductive health education is often
mixed-up with the controversial sex education,
school’s curricula mostly only provide limited
courses incorporated into Biology or sport science.
Whilst adolescents need more space to discuss the
changes in their bodies, little is known what schools
can accommodate.
The present study attempts to bridge the gap of
information that adolescents needed. Vaginal hygiene
module is designed for students as structured
education program. The module enables students to
independently explore their curiosity and facilitate
them to have better understanding of the subjects.
The results showed there is a significant difference in
the students’ attitude and practice in pathological
vaginal discharge prevention between intervention
and control group. The students who exposed to
vaginal hygiene module for six months showed better
attitudes and practice in pathological vaginal
discharge prevention compared to their counterpart in
control group who do not receive any module. The
study implies, knowledge improvement may lead to
positive attitudes and better practice, because
attitudes gradually change with supportive
environment. The module as one of supportive
elements has its strength in providing access at the
users’ convenience. Adolescent females who reluctant
to discuss about their genital organ may access the
module anytime and overtime, thus, providing a better
understanding of the sensitive issue.
Theoretically, human behavior is considered as a
result of cognitive process, including perception that
predicts the likelihood of individuals in engaging the
intended behavior. Behaviors (response) are also
influenced by information received from the
environment (stimulus). Perception is also proceeded
by stimulus which contained of information than can
be stored and recalled anytime (17, 18). Not only
affecting the cognitive aspect, the 6-months
continuous exposure from the module also showed
the students’ motivation in finding information
regarding their own reproductive health care and
prevention. Students who have positive attitudes

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 Sumarah and Widyasih
toward pathological vaginal discharge prevention are
more likely to have better practice and ultimately will
reduce the probability of infection.
It is true that the provision of vaginal hygiene
module was able to improve attitudes and practice,
shown by the overall score of students from pretest to
posttest. However, attention should be addressed to
specific behavior where most adolescents had a poor
practice such as changing panty liners and wearing
tight jeans as daily outfits. In general, the vast
majority of students do not understand that they have
to change panty liners at least 4 times a day to
prevent pathological vaginal discharge. After the
intervention, only 37.5% of students changed their
behavior. The likelihood of attitudinal changes was
also less in terms of changing their daily outfits. The
information provided in the module was unable to
change the students’ preference for tight jeans. The
economical cost of behavior changes perhaps can
explain why their attitudes are less likely to change.
Changing panty liners four times a day of course will
be an additional burden for their parents while
changing their existing daily outfits will be costly too.
Therefore, health promoter should be very careful in
conveying the message especially if it’s related to
additional cost of behavior changes.
Unlike practice that can be observed, attitudes
somehow are difficult to be measured. However,
attitudinal changes were captured from the posttest
results. Although significant attitude changes was
observed in terms of changing menstrual pads while
at school, it should be noted that the students’
knowledge on the use of soap as vaginal douche was
lacking. While knowledge was not assessed in the
present analysis, the students’ knowledge was somehow
reflected from their attitudes. Misbelieved and
misunderstanding on the use of soap as vaginal douche
therefore should be the center of attention for the health
providers for the future health promotion programs.
It should also be noted that human behavior itself
is a result of individual and environmental forces.
The long duration (6 months) of intervention also
should rise a precaution of contamination. Since it is
not possible to isolate the subject of intervention, the
knowledge, attitude and behavioral changes probably
are not only the results of the module provision but as
their interaction with external factors such as their
peers and other media exposures. Therefore, further
research should seek a better methods in measuring
the net impact of the health education tools to
behavior changes. Furthermore, since adolescents are
108 Vol. 11, No. 2, June 2017 http://jfrh.tums.ac.ir
socially active and not possible to be isolated, future
research should combine several possible factors such
as peers and media to obtain a better estimate of
behavioral changes.
Conclusion: There is a significant difference in
the students’ attitude and practice of pathological
vaginal discharge prevention between intervention
and control group. The students who exposed to
vaginal hygiene module for six months showed better
attitudes and practice in pathological vaginal
discharge prevention compared to their counterparts
in control group who do not receive any modules.
The results implied that vaginal hygiene module can
be provided widely for female adolescents at their
early puberty. The information provided in the
module should address specific behaviors where most
adolescents had poor practice such as changing panty
liner and wearing loose pants. District health officers
should work closely with schools’ health promoter to
reach the students and create a supportive
environment for reproductive health discussion and
forum in order to achieve better adolescents’
reproductive health status.
Conflict of Interests
Authors have no conflict of interests.
Acknowledgments
Authors would like to acknowledge the funding
support "Riset Pembinaan Tenaga Kesehatan" from
National Institute of Health Research and
Development (Badan Pengembangan dan
Pemberdayaan Sumber Daya Kesehatan), Ministry of
Health of Republic of Indonesia.
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Citation: Sumarah S, Widyasih H. Effect of Vaginal
Hygiene Module to Attitudes and Behavior of
Pathological Vaginal Discharge Prevention
Among Female Adolescents in Slemanregency,
Yogyakarta, Indonesia. J Fam Reprod Health 2017;
11(2): 104-9.
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